As the Pharmacy and Therapeutics (P&T) committee acts as an advisory committee on therapeutic options, it is important during pandemics, such as the current Coronavirus disease 2019 pandemic, to quickly search the evidence, be able to select the most appropriate therapies despite the limited evidence, and make appropriate decisions related to which drugs to procure and stock. Potential therapies and recommendations to the P&T committee at a large healthcare institution as means of a preparedness plan are reviewed here.
On December 31, 2019, a pneumonia of unknown cause in Wuhan, China was reported to the World Health Organization's Country Office. The Coronavirus disease 2019 (COVID-19) quickly turned into a global concern with its rapid spread.
After the initial outbreak in China, many other countries have also documented cases, spreading to more than 202 countries, with 754,948 confirmed cases globally and 36,571 deaths as of March 31, 2020. The highest numbers of confirmed COVID-19 cases were reported from China, Italy, United States, Spain, Germany, and Iran. Mortality rates have been reported to be same between Italy and China reaching 2.3%, the top two affected countries in this pandemic.
On March 2, 2020, the Saudi Ministry of Health announced its first case of COVID-19 in the kingdom, in a Saudi patient whom had returned from Iran. At the time of submitting this paper, the total number of cases had increased to 1563 as of March 31, 2020. Of particular concern to the country during this pandemic is the high influx of Muslims to the country for pilgrimage; therefore, as a precautionary measure the Saudi government decided to suspend the Umrah pilgrimage and revisit the decision periodically. This was followed by other strict measures to combat the virus, such as closing schools and curfews in most of its major cities.
At the National Guard Health Affairs (NGHA) in Riyadh, Saudi Arabia, any global outbreak brings back memories of the hospital's shutdown during the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) outbreak in the summer of 2015, that experience built a sense of accountability and resilience to contain MERS-CoV and any other similar outbreaks in the future. The hospital's leadership continued to take measures to break the transmission and ensure vigilance and preparedness for other infectious outbreaks. Very soon after the outbreak of COVID-19, the institution provided guidelines for employees travelling to any of the affected countries, suspended the fingerprint biometric attendance system, and held online educational awareness sessions about COVID-19.
The World Health Organization has developed a critical preparedness, readiness, and response actions for COVID-19 plan, with guidance based on the following four transmission scenarios for COVID-19:
Countries with no cases (no cases);
Countries with 1 or more cases, imported or locally detected (sporadic cases);
Countries experiencing cases clusters in time, geographic location, and/or common exposure (clusters of cases); and
Countries experiencing larger outbreaks of local transmission (community transmission).
At this time Saudi Arabia is in scenario 3. Under the guidance, there is a link to a clinical management tool specifically for COVID-19 and under module 7 (antimicrobial therapies) they state there are no known effective antivirals for COVID-19.
As an integral part of the hospital's steering committees, the pharmacy & therapeutics (P&T) committee, is charged with providing advice to the rational use of medications throughout the institution; our P&T committee at NGHA discussed our COVID-19 preparedness plan from a pharmacologic therapeutic prospective. The NGHA is one of the largest healthcare institutions in Saudi Arabia, with a bed capacity of 3577 collectively between its medical cities.
The aim of this plan was to identify all potential treatments, review the available evidence, and provide advice to the hospital's committee on decisions related to drug therapy based on resources, the limited evidence at the time and the current national COVID-19 situation.
The preparedness plan development included assembling a multidisciplinary team, identifying and reviewing evidence on potential treatments, treatment selection, and finally continuous assessment of stocks and logistical considerations.
Identifying Treatment Options and Evidence Review
The main central region P&T coordinator conducted a systematic review of published studies on PubMed, to identify studies examining therapeutic drugs for treatment of COVID-19. Key words used were “2019 novel coronavirus,” “Wuhan virus,” “COVID-19,” and “SARS-CoV-2.” All theory based, in vitro, animal, or human studies proposing potential therapies published between December 2019 and March 2020 were included. All articles were screened for treatment modalities in patients treated in the current outbreak, so descriptive observational studies were included. Studies on therapeutic drugs used in SARS-CoV and MERS-CoV were excluded.
Studies were categorized into human studies in patients infected with current COVID-19, in vitro studies, and studies that were based on theoretic efficacy. For articles published in Chinese, translation was done through google translate. Outcomes were listed, if reported in the study. Formulary status and cost of the potential drug therapies were also added to support the committee's decision.
Together, the chair of the P&T, the pharmaceutical planning department, and the pharmacoeconomic center, reviewed recommendations and continuous evaluation of the therapeutic options and measures that needed to be taken.
A total of 1528 articles were related to COVID-19 on PubMed as of March 26, 2020. Only 20 were related to therapeutics and were used for a full review. A list of identified studies is in Table 1. The majority were (ahead of print), had only abstracts available, or were in Chinese language.
Of 20 studies included, 14 were in patients in the current COVID-19 outbreak, two were in vitro studies, and four were articles reviewing theoretic concepts for treating COVID-19. Of 14 observational studies, one was in the United States, one in Singapore, one in France, one in Korea, and all the rest in China.
The list of the studies was used to formulate recommendations to the hospital's P&T committee on increasing stock and availability of certain drugs as a mean of preparedness for the worsening of COVID-19 outbreak. Because of the limited number of cases locally at the time of developing this plan and the strict quarantine measures taken by the government, the criteria for selection was as follows: only select treatments that were used in clinical studies during the outbreak, which showed relative effectiveness, no reported harm, and were easily accessible (i.e., available locally).
Most of the studies did not report any clear outcomes and no conclusions could clearly be drawn, but drugs that were used in current COVID-19 patients were recommended to be stocked, except for remdesivir as it is not available on the market except through special access and published data were only from one patient.
The list of drugs from in vitro studies or theoretically based were listed to clarify that there was still not enough evidence to recommend them in light of the availability of the other treatments. A decision was made not to recommend these drugs at the time of this review.
Recommended drugs based on the mentioned criteria
The following drugs were recommended: chloroquine, hydroxychloroquine + azithromycin, lopinavir/ritonavir, oseltamivir, and ribavirin.
The role of P&T committees during this pandemic is to provide continuous advice on emerging therapies and contain misinformation or exaggeration of proposed therapies that may have not proven any efficacy yet. As healthcare resources can become compromised during these times, institutions need to concentrate their efforts on ensuring continuous supply of supportive medications and be ready to face the challenging situation of distributional justice, having to choose between allocating resources to treatments that provide care to patients that show better hopes of survival.
P&T committees need to meet more frequently to assess the situation and plan for the worst-case scenario. At the time of this review, many proposed therapies were under investigation; however, very few besides lopinavir/ritonavir, chloroquine, ribavirin, and hydroxychloroquine + azithromycin, were clinically used or had any reported outcomes. Institutions need to explore potential unproven therapies carefully while weighing priorities and its burden on resources.
Drug Logistical Considerations
Frontline doctors from Wuhan describe the lack of drugs as a problem during the outbreak. Drug shortages are expected as supplies of active pharmaceutical ingredients are interrupted by closure of factories in China, which in turn supply 70% of raw material to India one of the largest suppliers of generic drugs in the world.
Therefore, beside antiviral directed treatments, identifying supportive drugs needed for infected patients may be more important during the pandemic, and assessing adequate stocks as demand is expected to increase. Shortages and lack of adequate planning may on its own increase mortality significantly. Efforts to identify early signs of supply chain shortages in supportive drugs, such as fluids and electrolytes, anti-inflammatories, steroids, and antibiotics for secondary infections, should continuously be assessed by the committee together with monitoring emerging logistical constrains and stock levels.
From the very start of the outbreak continues communication and coordination between P&T committee and our Pharmaceutical Planning Department (PPD) was almost on a daily basis, to ensure adequate stocks and prepare for increase in demand. The PPD reported during this time a surge in demand for the potential COVID-19 drugs in the market, but despite that, no increase in consumption at our institution was noted at the time of writing this paper. The PPD did however report a significant increase in drug transportation fees for a couple of drugs in the market, which affected net price for some other drugs procured by PPD.
Forecasting and estimating number of patients
Earlier during the outbreak, the Reproduction number (R) was reported to be 2.2, R is the average number of individuals to whom each infector will transmit the virus. When R is greater than 1, sustained transmission can occur; if R is less than 1, then chains of transmission will simply halt. Special about COVID-19 is the fact there is a significant number of asymptomatic infected individuals, known as recessive infections, that act as a source of infection during the outbreak, and therefore forecasting can be challenging. More recent reports show the R has dropped to less than 1 in most municipalities in China. A Chinese group developed a model to forecast the trend of COVID-19 infections, based on the (susceptible exposed infectious recovered) model. This model considers the COVID-19 transmission mechanism, infection spectrum, and prevention and control procedures. They predicted the inflection point of the epidemic has passed, but had not ended. In another predictive paper, the authors predicted the outbreak would end in China after March 20, 2020, and it did.
Researchers explain why containment efforts can only help delay the spread and buy us time to prepare, and how these efforts will not prevent a pandemic. As Saudi Arabia has only sporadic cluster cases at this time, with known exposure through travel, it is hard to predict the number of patients and rough estimates can only be done based on other country's experiences.
Italy's experience might serve as a good predictor for a worse-case scenario where the numbers of infected showed an exponential growth. From February 22, 2020 to March 11, 2020, the number of cases went from seven confirmed to 10,149 cases. Together with reports form a systematic review of clinical features of COVID-19 patients describing 20% required treatment in the intensive care unit, a worse-case scenario estimate number of patients that would be considered sever and be candidates for antiviral therapy can be made.
Accessibility and Cost
Of the potential treatments for COVID-19, hydroxychloroquine/chloroquine + azithromycin are the cheapest regimens, while lopinavir-ritonavir was more expensive with less supporting evidence on better outcomes compared with hydroxychloroquine + azithromycin. See Table 2 for cost of drug regimens.
All the recommended drugs are registered with the Saudi Food and Drug Authority with multiple suppliers locally listed.
Tocilizumab had no clinical studies in human, and its theoretic use in COVID-19 is based on relieving the cytokine storm syndrome not on any antiviral effect. It is an expensive drug, but was available on our formulary and no accessibility problems were noted at the time; however, no recommendation to increase stocks was made because of limited evidence and high cost.
Summary of recommendations made to P&T committee
Increase existing stocks of the following drugs: lopinavir/ritonavir, chloroquine, ribavirin, hydroxychloroquine, azithromycin, and oseltamivir.
To estimate the number of patients that would require antiviral drugs based on the local number of affected cases, predictions using other countries' trends, and an estimation of 20% of cases being moderate to severe, and to review this decision periodically based on trend of actual number of cases.
All listed potential treatments should be secured in controlled area in the pharmacy to control the stock and restricted in the electronic healthcare system.
Increase supply of all supportive treatments as follows:
Fluids: crystalloids (normal saline and Ringer's lactate) and electrolytes
Vasopressors (i.e., norepinephrine, epinephrine, vasopressin, and dopamine)
Low-molecular-weight heparin and heparin
Neuromuscular blockade (e.g., cisatracurium)
To develop an antiviral protocol for COVID-19 treatment, to include patient criteria for treatment and recommended doses
Daily stock monitoring of the potential treatments listed
Monitoring emerging therapies
The rapid Chinese researchers' response to the outbreak made the virus genome sequence quickly available (GenBank ID: MN908947.3). In which high-sequence homology was found to be shared with SARS-CoV. As a result, most of what has been published are theoretic proposed treatments based on previous studies targeting SARS-CoV and MERS-CoV.
Many clinical trials are undergoing to determine possibly effective therapies, which have included the following drugs: lopinavir plus ritonavir and arbidol, remdesivir, darunavir and cobicistat, favipiravir, ruxolitinib, baloxavir, marboxil, hydroxychloroquine, camrelizumab, tocilizumab, and immunoglobulin. No recommendations to procure or increase stock of any of these medications were made at this time.[17–20]
As the P&T committee acts as an advisory committee on therapeutic options, it is important during such epidemic outbreaks to quickly search the evidence, be able to debunk misinformation, select the most appropriate therapies despite the limited evidence, and conduct ongoing surveillance for emerging therapeutic options and make appropriate decisions.
The main challenge at the time of this research was most articles were published in Chinese language and available only as abstracts. Most studies were of very poor to poor quality with limited number of patients to clearly extrapolate effectiveness.
Source of Support: None. Conflict of Interest: None.